Screening for psychological distress before radiotherapy for painful bone metastases may be useful to identify patients with high levels of distress

Figures & data

Table 1. Baseline characteristics and level of psychological distress.

		PD low	PD intermediate	PD high			Differences
Baseline variables	All patients	(7 to 11)	(12 to 16)	(17 to 28)	PD unknown		between
n	1157	457	337	290	73	p value*	(p value)*
Primary tumor						.016
Breast	451 (39%)	161 (36%)	129 (38%)	138 (38%)	23 (32%)		Low–intermediate: .414
Prostate	267 (23%)	111 (24%)	87 (26%)	54 (19%)	15 (21%)		Low–high:.008
Lung	287 (25%)	119 (26%)	85 (25%)	59 (20%)	24 (33%)		Intermediate–high : .025
Other	152 (13%)	66 (14%)	36 (11%)	39 (13%)	11 (15%)
Age						.308
≤65 years	565 (49%)	218 (48%)	178 (53%)	139 (48%)	30 (41%)
>65 years	592 (51%)	239 (52%)	159 (47%)	151 (52%)	43 (59%)
Gender						<.001	Low–intermediate: .471
Male	624 (54%)	268 (59%)	189 (56%)	123 (42%)	44 (60%)		Low–high: <.001
Female	533 (46%)	189 (41%)	148 (44%)	167 (58%)	29 (40%)		Intermediate–high: .001
KPS						<.001
90–100	221 (19%)	97 (21%)	80 (24%)	34 (12%)	10 (14%)		Low–intermediate: .612
70–80	592 (51%)	244 (53%)	169 (50%)	145 (50%)	34 (47%)		Low–high: <.001
20–60	344 (30%)	116 (25%)	88 (26%)	111 (38%)	29 (40%)		Intermediate–high: <.001
Pain score						.497
2–5	428 (37%)	172 (38%)	123 (37%)	110 (38%)	23 (32%)
6–7	362 (31%)	144 (32%)	118 (35%)	83 (29%)	17 (23%)
8–10	367 (32%)	141 (31%)	96 (29%)	97 (33%)	33 (45%)
VRS-vl^a						<.001	Low–intermediate: <.001
1–3	350 (30%)	189 (41%)	92 (27%)	48 (17%)	21 (29%)		Low–high: <.001
4	364 (32%)	152 (33%)	113 (34%)	75 (26%)	24 (33%)		Intermediate–high: <.001
5–7	443 (38%)	116 (25%)	132 (39%)	167 (58%)	28 (38%)
VAS-gh^a						<.001
0–33	236 (20%)	127 (28%)	71 (21%)	30 (10%)	8 (11%)		Low–intermediate: .043
34–66	530 (46%)	220 (48%)	164 (49%)	108 (37%)	38 (52%)		Low–high: .001
67–100	391 (34%)	110 (24%)	102 (30%)	152 (52%)	27 (37%)		Intermediate–high: <0.001
Visceral metastases						.904
No	838 (72%)	331 (72%)	244 (72%)	214 (74%)	49 (67%)
Yes	319 (28%)	126 (28%)	93 (28%)	76 (26%)	24 (33%)
Systemic therapy						.205
No	531 (46%)	215 (46%)	156 (46%)	118 (41%)	42 (57%)
Yes	626 (54%)	242 (54%)	181 (54%)	172 (59%)	31 (43%)
Treatment arm						.215
6 × 4 Gy	578 (50%)	218 (48%)	180 (53%)	138 (48%)	42 (58%)
1 × 8 Gy	579 (50%)	239 (52%)	157 (47%)	152 (52%)	31 (43%)
Pain medication						.112
No opioids	667 (58%)	279 (61%)	200 (59%)	155 (53%)	33 (45%)
Opioids	490 (42%)	178 (39%)	137 (41%)	135 (47%)	40 (55%)
Localization of pain						.41
Extremities	173 (15%)	76 (17%)	45 (13%)	44 (15%)	8 (11%)
Spinal column	345 (30%)	119 (26%)	109 (32%)	93 (32%)	24 (33%)
Pelvis	455 (39%)	183 (40%)	134 (40%)	109 (38%)	29 (40%)
Other	184 (16%)	79 (17%)	49 (15%)	44 (15%)	12 (16%)

* Pearson Chi-Square.

^a VRS-vl and VAS-gh: the lower, the better QoL.

KPS: Karnofsky performance score; VRS-vl: verbal rating score, valuation of life; VAS-gh: visual analog score, general health; Gy: gray.

Table 2. Univariate (UVA) and final multivariate (MVA) logistic regression analyses on potential baseline predictors for high level of psychological distress before palliative radiotherapy for painful bone metastases.

	Odds ratio (95% CI)
Baseline variables	UVA^c	MVA^c
Primary tumor
Breast	1.00	^a
Prostate	0.57 (0.40–-0.820)
Lung	0.61 (0.43–0.87)
Other	0.80 (0.53–1.22)
Age
≤65 years	1.00	1.00
>65 years	1.08 ( 0.83–1.420)	1.28 (0.95–1.73 )
Gender
Male	1.00	1.00
Female	1.84 (1.40–2.42 )	1.94 (1.44–2.62 )
KPS
90–100	1.00	1.00
70–80	1.83 (1.21–2.76 )	1.44 (0.92–2.24 )
20–60	2.83 (1.84–4.37 )	1.67 (1.03–2.70 )
Pain score
2–5	1.00	1.00
6–7	0.85 (0.61–1.18 )	0.65 (0.46–0.94 )
8–10	1.10 (0.80–1.52 )	0.60 (0.42 - 0.87)
VRS-vl^b
1–3	1.00	1.00
4	1.66 (1.11–2.47)	1.40 (0.91–2.17 )
5–7	3.94 (2.74–5.67)	2.54 (1.63–3.96 )
VAS-gh^b
0–33	1.00	1.00
34–66	1.86 (1.20–2.88)	1.43 (0.88–2.31)
67–100	4.73 (3.06–7.32)	2.64 (1.55–4.48)
Visceral metastases
No	1.00	^a
Yes	0.93 (0.69–1.26)
Systemic therapy
No	1.00	^a
Yes	1.28 (0.97–1.68 )
Treatment arm
6 × 4 Gy	1.00	^a
1 × 8 Gy	1.11 (0.85–1.45)
Pain medication
No opioids	1.00	^a
Opioids	1.32 (1.01–1.74 )
Localization of pain
Extremities	1.00	^a
Spinal column	1.12 (0.74– 1.71)
Pelvis	0.95 (0.63–1.42)
Other	0.95 (0.58–1.54)
Time since primary tumor
Continuous	1.00 (1.00–1.00)	^a

^a did not remain in the final model.

^b VAS-gh, VRS-vl: the lower the score, the better QoL.

^c logistic regression analysis.

KPS: Karnofsky performance score; VRS-vl: verbal rating score, valuation of life; VAS-gh: visual analog score, general health; Gy: gray; 95% CI: 95% confidence interval; UVA: univariate analysis; MVA: multivariate analysis

Figure 1. Mean scores of psychological distress (sum score ranges between 7 (low) and 28 (high)) at baseline (measurement 0) and after radiotherapy for painful bone metastases. (A) All patients (n = 1084) and all patients who still returned their questionnaires after 12 weeks (n = 679). (B) Patients with a high (n = 290), intermediate (n = 337) and low level (n = 457) of psychological distress at baseline. Y-axis: mean scores of psychological distress. X-axis: measurement. The first 12 measurements after baseline were taken weekly and thereafter monthly.

Figure 2. Percentage of patients with a low, intermediate or high level of PD during follow-up. Y-axis: percentage of patients. X-axis: measurement. The first 12 measurements after baseline were taken weekly and thereafter monthly.